Anesthetic efficacy of mental/incisive nerve block compared to inferior alveolar nerve block using 4% articaine in mandibular premolars with symptomatic irreversible pulpitis: a randomized clinical trial

Present status and future directions - Mechanisms and management of local anaesthetic failures

Pain control during root canal treatment is of utmost importance for both the patient and the dental practitioner and many studies have investigated ways of overcoming problems with gaining adequate anaesthesia during treatment. The PubMed and Cochrane databases were searched for evidence-based studies regarding local anaesthesia for root canal treatment. Many variables, including premedication, pain during needle insertion, pain on injection, premedication with various types of drugs, volume of anaesthetic solutions, supplemental anaesthetic techniques, and additives to the anaesthetic solutions, may influence pain perception during root canal treatment. Differences between teeth with healthy pulps versus those with irreversible pulpitis should be considered when the effects of variables are interpreted. There are several concerns regarding the methodologies used in studies that have evaluated anaesthesia success rates. There are some conditions that may help to predict a patient's pain during root canal treatment and these conditions could be overcome either by employing methods such as premedication with a non-steroidal anti-inflammatory drug prior to the treatment visit or by using supplementary anaesthetic techniques before or during the treatment. However, authors need to be more careful when reporting details of their studies to reduce concerns regarding their study bias.

Needle-free Mental Incisive Nerve Block:In vitro, Cadaveric, and Pilot Clinical Studies

The present study aimed to optimize Needle-Free Liquid Jet Injection (NFLJI) for Mental Incisive Nerve Blocks (MINB) and evaluate its clinical safety and feasibility. A MINB protocol was developed and optimized by series of NFLJI experiments in soft tissue phantoms and cadavers, then validated in two pilot Randomized Controlled Trials (RCT). The NFLJI penetration depth was found to be directly proportional to the supply pressure and volume. High-pressure NFLJIs (620 kPa or above) created maximum force and total work significantly greater than needle injections. Low-pressure NFLJIs (413 kPa), however, produced results similar to those of needle injections. Additionally, high-pressure NFLJIs created jet impingement pressure and maximum jet penetration pressure higher than low-pressure NFLJIs. Pilot RCTs revealed that high-pressure NFLJI caused a high risk of discomfort (60%) and paresthesia (20%); meanwhile, low-pressure NFLJI was less likely to cause complications (0%). The preliminary success rates of MINB from cadavers using NFLJIs and needles were 83.3% and 87.5%. In comparison, those from RCTs are 60% and 70%, respectively. To conclude, NFLJI supply pressure can be adjusted to achieve effective MINB with minimal complications. Furthermore, the cadaver study and pilot RCTs confirmed the feasibility for further non-inferiority RCT.

Effectiveness of different anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis: a systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to assess the effectiveness of anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis, comparing to the inferior alveolar nerve block (IANB) by meta-analysis.

MATERIALS AND METHODS

Studies were identified from Cochrane Library, Embase, Lilacs, PubMed, Scopus, and Web of Science databases up to May 2021. Randomized clinical trials comparing the anesthetic success rate of IANB and any other alternative anesthetic method were included. The quality of the selected studies was assessed by the Cochrane Risk of Bias 2.0 tool. Meta-analyses using Mantel-Haenszel method and random-effect models were performed to find the pooled estimates of risk ratio (RR) with 95% confidence interval (CI). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Twenty-two studies were selected, which included fourteen anesthetic methods. Two studies were classified as high risk of bias, five as uncertain risk and fifteen as low risk. Vazirani-Akinosi nerve block (VANB) [RR = 1.27; p = 0.007; 95% CI, 1.07-1.52; I² = 0%] and intraosseous injection (IOI) [RR = 1.48; p = 0.04; 95% CI, 1.02-2.15; I² = 46%] had superior effectiveness compared to IANB, with low certainty of evidence, as well as buccal infiltrations associated with IANB (BI + IANB) [RR = 1.84; p = 0.004; 95% CI, 1.22-2.79; I² = 52%], with very low certainty.

CONCLUSION

Evidence suggests that buccal infiltrations associated with IANB, VANB, and IOI are more effective than IANB at anesthetizing posterior mandibular teeth with symptomatic irreversible pulpitis.

CLINICAL SIGNIFICANCE

Alternative primary methods of anesthesia might be indicated for mandibular posterior teeth presenting symptomatic irreversible pulpitis.

Critical analysis of the reporting quality of randomized trials within Endodontics using the Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) 2020 quality standard checklist

AIM

To critically evaluate the reporting quality of a random sample of clinical trials published in Endodontics against the PRIRATE 2020 checklist and to analyse the association between the quality of reported trials and a variety of parameters.

METHODOLOGY

Fifty randomized clinical trials relating to Endodontics were randomly selected from the PubMed database from 2015 to 2019 and evaluated by two independent reviewers. For each trial, a score of '1' was awarded when it fully reported each item in the PRIRATE guidelines whereas a score of '0' was awarded when an item was not reported; when the item was reported inadequately a score of '0.5' was awarded. For the items that were not relevant to the trial, 'Not Applicable (NA)' was given. Based on the interquartile range of the overall scores received, trials were categorized into 'Low' (0-58.4%), 'Moderate' (58.5-72.8%) and 'High' (72.9-100%) quality. The associations between characteristics and quality of clinical trials were investigated. Descriptive statistics, frequency analysis and percentage analyses were used to describe the data. To determine the significance of categorical data, the chi-square test was used. The probability value 0.05 was considered as the level of significance.

RESULTS

Based on the overall scores, 13 (26%), 25(50%) and 12 (24%) of the reports of clinical trials were categorized as 'High', 'Moderate' and 'Low' quality, respectively. Three items (1b, 6d, 11e) were adequately reported in all manuscripts whilst two items (5k, 5m) were scored 'NA' in all the reports. The reports published from Europe had a significantly greater percentage of 'High'-quality scores, compared to Asia, Middle East, North America and South America (P = 0.0002). The 'High'-quality reports were published significantly more often in impact factor journals (P = 0.045). Reports of clinical trials published in journals that adhered to the CONSORT guidelines had significantly more 'High' scores compared to those that did not (P = 0.008). Clinical trials with protocols registered a priori had a significantly greater percentage of 'High' scores compared to the trials that were not registered in advance (P = 0.003). No significant difference occurred between the quality of clinical trials and the number of authors, journal (Endodontic specialty vs. Non-Endodontic specialty) or year of publication.

CONCLUSIONS

Reports of randomized clinical trials published in the speciality of Endodontics had a substantial number of deficiencies. To create high-quality reports of clinical trials, authors should comply with the PRIRATE 2020 guidelines.

Efficacy of Pulpal Anesthesia Using a Needle-less Syringe

The purpose of this study was to investigate the manufacturer's claims regarding a novel needleless intraligamentary local anesthesia injection device (Numbee, BioDent) to provide effective single tooth anesthesia. Investigators compared the Numbee with a traditional inferior alveolar nerve block (IANB) during a restorative procedure on mandibular teeth. A randomized, split-mouth design was conducted with 15 adult subjects receiving an IANB on one side and a Numbee injection on the same tooth type on the contralateral side. Subjects recorded injection pain using the Visual Analog Scale (VAS) and their preferred injection technique. Anesthesia was considered profound with 2 consecutive electric pulp tester readings of 80. If subjects became symptomatic during the restorative procedure, rescue anesthesia was administered. The difference in VAS scores for injection pain between the Numbee and the IANB was not significant (p = .078). For the IANB, the incidence of profound anesthesia was 46%, and required rescue anesthesia was 20%. For the Numbee, the incidence of profound anesthesia was 0%, and required rescue anesthesia was 60%. Subject preference was evenly split (50/50%) between the 2 techniques. The IANB outperformed the Numbee device for achieving profound anesthesia and requiring less rescue anesthesia.

The success of using 2% lidocaine in pain removal during extraction of mandibular premolars: a prospective clinical study

BACKGROUND

The purpose of this study was to evaluate the anesthetic effectiveness of a buccal infiltration technique combined with local massage (using 2% lidocaine) in the extraction of mandibular premolars to be utilized as an alternative to the conventional inferior alveolar nerve block.

METHODS

Patients eligible included any subject with a clinical indication for tooth extraction of the mandibular 1st or 2nd premolars. All patients were anesthetized buccally by local infiltration technique followed by an external pressure applied for 1 min directly over the injection area. In each case, another local injection was given lingually. All operations were started at approximately 5 min after the buccal injection. The collected data included age, gender, pain perception and its intensity during treatment at three checkpoints, apical tenderness, and the type of extraction. Any associated complications or difficulties were also recorded. Then the results were analyzed and interpreted using appropriate statistical tests. The significance level was set at P ≤ 0.05.

RESULTS

A total of 247 cases (1st premolar, n = 119; 2nd premolar, n = 128), predominantly male, were included. In 95% of study sample, the patients were satisfied with the dental extraction without any pain. However, in 5% of cases, pain was reported at the stage of tooth removal. Apical tenderness was found to be present in 11% of the total cases. Three teeth required surgical removal. Upon analysis, no significant differences in the success rates were detected between the 2 premolar groups or amongst the various age groups. Minor and transient side effects were reported in this study.

CONCLUSION

The technique is simple and effective as well. It might be considered as an alternative anesthetic injection to the inferior alveolar nerve block for dental extraction of the mandibular premolars.

Anesthetic Efficacy of Gow-Gates, Vazirani-Akinosi, and Mental Incisive Nerve Blocks for Treatment of Symptomatic Irreversible Pulpitis: A Systematic Review and Meta-analysis with Trial Sequential Analysis

INTRODUCTION

This systematic review compared the anesthetic efficacy between Gow-Gates (GG), Vazirani-Akinosi (VA), and mental incisive (MI) nerve blocks (NBs) with inferior alveolar nerve blocks (IANBs) in mandibular teeth with irreversible pulpitis using meta-analysis and trial sequential analysis (TSA).

METHODS

Studies were identified from 4 electronic databases up to June 2019. Randomized clinical trials (RCTs) comparing the anesthetic success rate of GG, VA, and MI NBs with IANBs in mandibular premolars and molars with irreversible pulpitis were included. The quality of selected RCTs was appraised using the revised Cochrane risk of bias tool. Random-effects meta-analyses of risk ratio (RR) and 95% confidence intervals (CIs) were calculated, and random errors were evaluated by TSA. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Five RCTs were included; 2 of them were classified as low risk of bias. No significant difference was observed in the anesthesia success rate compared between GG and IA NBs (RR = 1.10; 95% CI, 0.82-1.48; I² = 0%). Similarly, no difference was evident between MINB and IANB (RR = 1.15; 95% CI, 0.97-1.36; I² = 0%). Overall, the cumulative success rates for the 3 anesthetic techniques were low. TSA showed a lack of firm evidence for the results of the meta-analysis between GG NB and IANB. The Grading of Recommendations, Assessment, Development and Evaluation approach evaluation showed that the evidence was of moderate quality for GG NB and IANB compared with low quality for MI and IA NBs. Because only 1 study was available comparing VA NB and IANB, a meta-analysis was not performed. The adverse effect associated with MI NB was swelling, whereas it was prolonged numbness for IANB.

CONCLUSIONS

GG NB and IANB showed similar anesthetic efficacy compared with IANB in mandibular teeth with irreversible pulpitis. However, the success rates for each technique indicate the need for supplemental anesthesia. Further well-designed RCTs evaluating different anesthetic techniques with and without supplemental injection are required to provide stronger evidence.

Position of the Mandibular Foramen in Different Facial Shapes Assessed by Cone-Beam Computed Tomography - A Cross-Sectional Retrospective Study

Purpose:

The mandibular foramen, located on the internal surface of the mandibular ramus, is an important anatomical landmark for the success during the inferior alveolar nerve block. This cross-sectional retrospective study aimed to evaluate the location of the mandibular foramen through Cone-Beam Computed Tomography (CBCT) in different facial shapes.

Materials and Methods:

The determination of the location of the mandibular foramen was performed using CBCT of mesocephalic, dolichocephalic and brachycephalic patients (n=40 each). The ramus width (W), the distance from the mandibular foramen to the deepest point of the anterior border of the mandibular ramus (D), the distance from the mandibular foramen to the lowest point of the mandibular notch (V) and the distance from the inferior border of the mandible to the lowest point in of the mandibular border (R), as well as the ratios W/D and V/R, were measured. ANCOVA, two-way ANOVA and Chi-square tests were used to analyze the variation among the facial shapes.

Results:

The ramus width (W) was greater (p<0.0001) in the brachycephalic (28.4±0.5 mm) than in both mesocephalic (26.8±0.36 mm) and dolichocephalic (25.5±0.39 mm) patients. D (p=0.0433) and R (p=0.0072) were also greater in the brachycephalic (17.7±0.36 mm; 43.4±0.75 mm, respectively) than dolichocephalic (16.5±0.3 mm; 40.3±0.63 mm, respectively), but both did not differ from mesocephalic (17.3±0.36 mm; 41.8±0.66 mm, respectively) patients. The other measurements (V, W/D and R/V) did not significantly differ among facial shapes.

Conclusion:

The localization of the mandibular foramen was, in the horizontal direction, more posterior in the brachycephalic patients and, in the vertical direction, higher in the dolichocephalic patients, when compared to the other groups analyzed. Thus, the anatomic data found in this study may help dentists to increase the success of the inferior alveolar nerve block and prevent surgical complications.